Provider Demographics
NPI:1851660807
Name:GABEN
Entity Type:Organization
Organization Name:GABEN
Other - Org Name:KNIGHTDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SEGMIA
Authorized Official - Middle Name:KENNA
Authorized Official - Last Name:TOHNYA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:443-621-4271
Mailing Address - Street 1:6602 KNIGHTDALE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6525
Mailing Address - Country:US
Mailing Address - Phone:919-295-1112
Mailing Address - Fax:919-295-1164
Practice Address - Street 1:6602 KNIGHTDALE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6525
Practice Address - Country:US
Practice Address - Phone:919-295-1112
Practice Address - Fax:919-295-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC111743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
6684760001Medicare NSC